Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Allergy History Form
Full Name *
Drug Allergies
| Allergy | Reaction |
|---|---|
Food Allergies
| Allergy | Reaction |
|---|---|
Environmental Allergies
| Allergy | Reaction |
|---|---|
Contact Allergies (Latex, etc.)
| Allergy | Reaction |
|---|---|
Reaction Severity & Type
Allergy Testing Results
| Allergy | Reaction |
|---|---|
Current Immunotherapy
Epinephrine Auto-Injector Prescribed
Patient Signature
Date
Allergy History Form template from formisoft.com. formisoft.com/intake-templates/allergy-history